South West Orthopaedic Club Meeting at Hereford , October 1991

In the abstracts that follow the author who presented the paper is marked with an *. The last two abstracts were poster demonstrations and the remainder were clinical papers. The X-ray quiz was won by Mr. D. Halpin of Torbay and the SWOC Prize certificate was won by Miss D. Eastwood of Bristol. The Pridie Memorial lecture entitled "South West Orthopaedics 1948-91" was given by Mr. A. H. C. Ratliff

Prophylaxis is used and there are many regimes. Claims are made for the efficacy of each regime.
Deep venous thrombosis can be reduced from around 70% to less than 15% by the use of an epidural for total hip replacement and the incidence of pulmonary embolus can be brought down to around 10%. This is because of increased circulation in the lower extremities, less activation of the clotting mechanism, and more efficient fibrinolysis. Regional blockade also confers the advantages of easier surgery, stress-free surgery, greater patient comfort post-operatively, better postoperative pulmonary function, less mental dysfunction and less blood loss. It is also likely that an epidural helps the cement/bone interface to be better, leading to longer prosthesis life.
General anaesthetic with spontaneous ventilation will cause some lowering of the venous pressure and thus of the venous channels in the bone of the lower limb. General anaesthetic with paralysis and intermittent positive pressure ventilation raises the venous pressure and, it is postulated, makes the cement/bone interface less effective.
An epidural, particularly when prolonged into the postoperative period, causes a marked reduction in the venous pressure and allows better joint cementing.
Cement/bone interface apart, workers from Uppsala in Sweden have stated that "epidural analgesia, prolonged into the post-operative period, in addition to other thrombo-prophylactic measures, should be of value in patients undergoing operations associated with a high risk of thromb-embolic complications . SHOULD ANKLE FRACTURES IN THE ELDERLY BE FIXED? (Paper) *W. J. Leach, M. J. F. Fordyce Truro To assess the results of ankle fracture fixation in the elderly, We have carried out a review of seventy-six patients aged over fl%, all of whom had ankle fracture fixation carried out in the two years 1989-1990. Case notes and pre-and post-operative X-rays were studied, ln Particular with respect to the early complications ot operative treatment.
Nine of the seventy-six patients (11.8%) developed one or m?re complications. Our series had a 1.8% incidence of mfection and a 5 2% incidence of delayed healing and wound necrosis. Malunion occurred in 7.9% of patients, and was due in all cases to imperfect per-operative reduction or inadequate fixation. In no case did fixation fail because of poor bone quality. There was no significant difference between the complication rates in males and females.
We conclude that internal fixation of ankle fractures in the elderly patient carries acceptable risks, so long as careful attention is paid to surgical technique, and fixation is in accordance with AO principles. In 1981 100 consecutive patients with displaced Colles' fracture were treated by closed reduction and cast immobilisation for five weeks. Patients were assessed clinically and radiologically after five weeks, 12 weeks and 10 years. 55 patients attended for follow up after ten years, 35 patients had died. 85% of patients had a clinically satisfactory result after ten years. Significantly more patients had an excellent wrist after ten years. At long term follow up 56% were pain free, 40% had a reduced grip strength; 64% showed objective cosmetic deformity and features of algodystrophy were present in 27 %. Osteoarthrosis was present in 45% of injured wrists after ten years, but the prevalence and severity was comparable in the uninjured wrist. Osteoarthrosis occurred more frequently in intra-articular fractures. Conclusion 85% of Colles' fractures are clinically satisfactory after ten years. Clinical results improve little after three months.
Displaced intra-articular fractures, wrist deformity and algodystrophy are associated with an unsatisfactory outcome. reviewed 9 months to 4 years (mean 2 years) post operatively, and weakness of hip abduction as compared to normal hip was assessed using a force transducer (BBC X7 Servigon).

EFFECT
Heterotopic ossification was noted in 21 (89%) patients and was graded according to Brumback (1990) criteria.
Three groups were identified: a) 8 patients did not have any abductor weakness (3 Grade 0, 3 Grade I, 2 Grade II heterotopic ossification) b) 8 patients had slight weakness (8-20%) of hip abduction, but were clinically normal (1 Grade I, 2 Grade II, 5 Grade III heterotopic ossification) c) 9 patients had significant (32-80%, mean 48.6%) weakness of hip abduction and were variably symptomatic (1 Grade 0, 4 Grade I, 3 Grade II and 1 Grade III heterotopic ossification). Grade III heterotopic ossification is usually associated with varying degree of weakness of hip abduction. Patients with significant weakness usually have associated contributory factors i.e. severe ipsilateral fractures and a long intramedullary nail. COMPOUND LOWER LIMB FRACTURES IN CHILDHOOD: A COMPLEX PROBLEM *Patricia Allen and Deborah Eastwood Frenchay Hospital, Bristol Compound fractures in childhood occur rarely but they pose complex problems for doctors involved in their management.
We have reviewed 8 children who had sustained Grade 2/3 compound fractures of the lower limb, distal to the knee. The average age of the patients was 10 years (range 7-15) and all sustained their injuries in road traffic accidents. The injuries consisted of 6 fractures of the tibia/fibula and 2 ankle/foot injuries. Six cases had an external fixator applied. The soft tissue procedures performed were: 5 fascio-cutaneous flaps, 1 vascularised free fibular graft and 2 free muscle flaps. In 5 cases soft tissue coverage was achieved rapidly, within 1 week, and in these patients there were less problems with swelling, infection and healing of the flaps. In 5 cases the fracture has united uneventfully, in 1 there is a delayed union with a painful fracture site at 5 months and in 2 cases, at 3 month follow up, union appears to be progressing. None of the injuries have so far been associated with any growth disturbances. We believe that children with these injuries should be treated aggressively with early external fixation of their fractures and prompt soft tissue coverage.
TRANSIENT SYNOVITIS OF THE HIP: AN IRRITATING EXPERIENCE *Deborah M. Eastwood Bristol Royal Infirmary In 1986, a retrospective review of children admitted to a Hospital with a painful hip was conducted. During 30 months there were 181 admissions, 165 with transient synovitis (TS). Although 25% had a raised white count, 39% a raised ESR and 21 % were pyrexial, no hip initially diagnosed as TS developed septic arthritis. 100 hips underwent an ultrasound scan and joint effusion was demonstrated in 54%. Management consisted of traction for those with an effusion and symptomatic treatment for those without. A local survey confirmed that most patients were treated similarly and followed-up routinely clinically and radiographically.
A 5 year review of all notes was performed and a clinical or telephone review achieved in 80%. No affected hip developed a slipped upper femoral epiphysis or Perthes' disease although in one child the contralateral hip developed Perthes' disease. Recurrent admissions with TS occurred in 12%. In 3 patients, the diagnosis of TS was changed to juvenile chronic arthritis and a further 3 cases re-presented with other pathology which accounted for their pain.
TS remams a diagnosis made by exclusion of other pathology but it is a discrete entity. Basic blood tests and an ultrasound scan will help identify patients who can be treated at home.
Routine clinical and radiological follow-up is not required. The purpose of the study was to determine the long term outcome of the Dillwyn Evans procedure for relapsed club feet and to establish whether the results deteriorate with time. Sixty feet in 45 patients average age 28.8 years were reveiwed at an average 22.6 years post-operatively. The feet were scored using five scoring systems, looking at function and deformity. Seven (12%) of the 60 feet had required triple fusion at skeletal maturity. Four feet (7%) required a repeat Dillwyn Evans procedure at an early stage. Six feet (11%) had deteriorated in the last ten years. However in three of these this was attributable to pre-existing joint damage rather than to time alone. Good or satisfactory results were scored by 60-80% of feet depending on the scoring system used. 90% of the patients were able to pursue unrestricted activities. In conclusion the rate of degenerative change and functional deterioration with time is low unless there is pre-existing joint damage. A scoring system based on function rather than deformity is more appropriate in this older age group. Posterior spinal fusion with screw fixation and early mobilisation without external support can be associated with significant lessening of pain in 80% of patients and improvement of physical activities rather less. Industrial accidents were not common in this series. The results in private patients, NHS patients and patients with proven previous psychiatric history were similar. The incidence of thromboembolism is particularly high following total hip replacement (THR). Deep vein thrombosis (DVT) occurs in 40-70% of patients and pulmonary embolism detected by scintigraphy in 20-25%. It is not known how many patients eventually suffer the post-phlebitic limb syndrome but 1-2% die from pulmonary embolism.

GOLFERS
Many prophylactic regimens have been described but none have proved ideal.
A recent report has shown a significant reduction in DVT formation in patients undergoing gynaecological operations, using a fixed peri-operative low dose of warfarin. This regimen has the advantages that there were no bleeding or wound healing complications and the patients could continue their prophylaxis after their discharge and return home.
The aim of this study was to perform a prospective, doubleblind, placebo controlled trial to assess the thrombo-prophylactic efficacy of this simple regimen in patients undergoing total hip replacement.
One hundred and forty-eight patients were randomly allocated to receive either one milligram of warfarin daily for one week prior and three weeks after surgery or a placebo for the same period.
The patients were well matched for age, sex, obesity score, type of arthritis and pre-operative activity.
All patients had their operation performed in the lateral decubitus position under a standardised general anaesthetic.
DVT was diagnosed using the 1-125 fibrinogen uptake method.
Blood tests were performed to establish any alteration in clotting function during the trial period. Blood loss was measured. The wounds were examined clinically and by ultrasound for wound healing problems or haematoma formation. All patients were reviewed six weeks post-operatively to establish whether any thrombo-embolic complications had occurred since discharge.
Results show: !? There was no difference in clotting function, blood loss, wound healing or haematoma formation.
2-No significant difference in DVT formation or the occurrence ?f pulmonary embolism between the two groups.
In conclusion, we have shown that fixed minidose warfarin has no thromboprophylactic effect in patients undergoing total hlP replacement and its use cannot be recommended. Return to Sport 70% of those wishing to do so returned to sport for 13 months to 6.5 years post operatively. 10 ruptured prostheses with further sports injury. Compact Diameter Prosthesis 67 patients 0-2.5 years, 100% review. Biology

As above
Effusions. 6 (9% The infrapatellar pad of the human knee is well described in anatomical texts, and the presence of a suprapatellar pad is used by radiologists in diagnosing small effusions. This demonstration is based on a study of 21 knees from unselected dissecting room cadavers. It points out that the infrapatellar and suprapatellar pads are linked along the medial and lateral borders of the patella to form a continuous circumferential fat pad. The name corona adiposa patellae is proposed for this structure. The pad forms a flexible part of the patellofemoral articulation, accommodating to movements of the joint and occupying the space around the articular margin of the patella. It sometimes overlaps the patellar articular cartilage and forms a pouch in which small loose bodies may lodge and evade discovery at arthroscopy.